Coordinated Care Guides detail arteriogram outcomes
By AnnMarie Papa, MSN, RN, CEN
Case Manager, Quality Management Services
Jeanes Hospital
Philadelphia
Critical pathways, called Coordinated Care Guides (CCGs), were developed at Jeanes Hospital as a map or blueprint for patient care. Our critical paths are called CCGs because of the multidisciplinary team's importance in their development, implementation, and evaluation process.
CCGs most often are developed to address high-volume, high-acuity, and high-volume diagnoses for the 223-bed hospital. But the number of short-stay procedures, however, is steadily increasing. The increase in short-stay procedures requires health care professionals to provide high-quality, comprehensive, and holistic care across the continuum for these patients, as well. A multidisciplinary team was established by the nurse case manager to develop a CCG for arteriogram/angioplasty, one of our more common procedures.
The development team included members from the following departments:
* surgery;
* angiography;
* nursing;
* case management;
* interventional radiology;
* quality management.
The chairman of the department of surgery first requested that committee members work in their respective departments to develop a rough draft of the CCG. Results were compiled and presented at the next committee meeting. The development team used the same format of existing CCGs, but incorporated a CCG for both inpatient and same-day procedures. Short-stay CCGs are orange and inpatient CCGs are pink to help staff quickly differentiate between inpatient and short-stay procedures.
The CCG organizes the patient's plan of care by incorporating multidisciplinary documentation. The arteriogram/angioplasty CCG's emphasis on multidisciplinary development means that all members of the team understand the expected course of treatment for each patient. This helps to improve the quality of patient care, promote patient advocacy, and maintain patient and staff satisfaction.
For example, the multidisciplinary plan of care is now incorporated into the first page of the arteriogram/angioplasty CCG. Patient problems and expected outcomes are identified, and any member of the multidisciplinary can address the problems and outcomes. Additional space is provided to individualize patient problems, such as a chronic or acute condition, family circumstances, or specific social and/or cultural needs. (To see how patient problems are listed and expected outcomes included, see the arteriogram/angioplasty Coordinated Care Guide, p. 88.)
The next page of the CCG contains an outline of the expected progression of the patient's experience. The outline serves as a guide to ensure quality and promote continuity of care. A staff nurse signs the outline at the end of each shift when the patient progresses according to the expected outcomes.
The CCG helps shorten a patient's treatment and recovery time, as well as decreases health care costs, although specific clinical and financial data are not yet available. Approximately 150 patients have been placed on the arteriogram/ angioplasty CCG since its implementation in October 1995.
A teaching graph, which also streamlines the documentation process, provides a coordinated teaching plan for the patient. The graph was developed by a nurse manager and surgical staff nurse.
When the patient education is complete, the appropriate member of the multidisciplinary team checks and initials the corresponding box for the covered topic.
Variances are documented on the last page of the CCG and are addressed concurrently during the patient's stay. Variances are analyzed monthly by the nurse case manager. Data from the variance report identify areas for process improvement and provide information needed to modify the CCG.
CCGs begin with evaluation/assessment
The Patient Information Booklet (PIB), an important aspect of the patient education component of the CCG, is written in a clear, conversational style using large, easy-to-read print. A case manager met with staff nurses on the surgical unit to organize the patient plan of care and develop the information compiled in the PIB.
The PIB provides a step-by-step explanation of the procedure and gives the patient an outline of the expected progression of care. The PIB also enables patients and/or family members to take a more active role in the treatment process by asking caregivers questions about treatments and procedures.
The development team's goal is to provide copies of the PIB to physicians for distribution when the physician determines that an arteriogram or angioplasty is necessary. Analysis during the arteriogram/angioplasty evaluation meeting conducted two months following implementation revealed that patients often did not receive the PIB in the physician office.
Most of Jeanes' surgical CCGs are initiated in the preadmission testing department.
So, at the committee's request, the arteriogram/ angioplasty CCG now begins in the preadmission testing department rather than the physician's office. That eliminates the task of keeping booklets stocked in each physician's office, and still enables the patient to receive the PIB prior to the day of the procedure.
Included in the preadmission testing is an initial assessment and evaluation. An assessment/ intervention form was developed by an interventional radiologist and the chief angiographer, who also is president of the medical staff. The assessment form spans the pre-procedure and post-discharge care continuum. (To see how patients are assessed throughout the procedure, see the Assessment/Intervention Form, p. 89.)
Following the pre-procedure screening and assessment, patients are instructed on dietary and post-procedure limitations. Following the procedure, the interventional radiology staff nurse completes the post-procedure assessment and forwards the form to the nurse case manager.
The nurse case manager follows the patient's progress during the hospital stay and makes follow-up phone calls 24 hours following surgery and one week after discharge. The follow-up calls are conducted to assess expected patient outcomes and reinforce discharge instructions.
A follow-up assessment is compiled post-discharge by the nurse case manager. Access to data from the entire continuum of care enables the nurse case manager to provide outcome documentation for use in benchmarking and identify areas for process improvement.
CCGs at Jeanes are creative tools used to enhance collaboration among members of the multidisciplinary team involved in the care of the patient. Implementation of this process has been challenging for all involved and has furnished a strong foundation for the development of prospective CCGs in the near future.
Both patients and family members are pleased with the RN contact before and after the procedure. Comments include: They feel comfortable knowing that someone will be checking on them; they feel part of the hospital family; the phone calls reduced their anxiety about returning home; and the booklet was very helpful.
Nurses are pleased with the streamlined documentation and the easy-to-use format of the CCG. A surgical unit nurse manager maintains that the CCG provides another resource for the orientation of new staff. The CCG, for example, outlines the standard of care and delineates expected discharge outcomes for new staff to use as a guide. Physicians are pleased with the entire process and recognize the value of outcomes documentation.
Patients are contacted 24 hours and one week following their procedure, to assess individual outcomes and gather patient satisfaction data. Patient satisfaction data are compiled monthly. *
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